Apgar Score and Newborn Assessment
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Direct answer
The Apgar score is a rapid five-component score, introduced by Virginia Apgar, that rates appearance, pulse, grimace, activity and respiration at one and five minutes after birth, with further scores at 10 minutes onward if the score stays low. Each component scores 0 to 2, giving a total of 0 to 10, and 7 to 10 is reassuring. Its main limit is that it describes the baby at scoring, so it does not diagnose hypoxia or predict long-term outcome.
What you must remember
- Appearance: skin colour. Completely pink scores 2, pink body with blue extremities scores 1, and blue or pale scores 0.
- Pulse: heart rate. Absent scores 0, below 100 bpm scores 1, and 100 bpm or above scores 2.
- Grimace: reflex irritability. No response scores 0, grimace scores 1, and cough, sneeze or cry scores 2.
- Activity: muscle tone. Limp scores 0, some flexion scores 1, and active movement scores 2.
- Respiration: breathing effort. Absent scores 0, slow or irregular scores 1, and good strong cry scores 2.
- Timing: recorded at one and five minutes; if the five-minute score is below 7, scoring continues at five-minute intervals (10 minutes and beyond) until stable.
- Limit: a poor predictor of long-term neurological outcome for an individual baby, and not a diagnosis of birth asphyxia.
Components and scoring bands
Examiners often ask for each component and its scoring band, so the table sets the five components side by side. Each row is scored out of two, and the pulse cut-off of 100 bpm (below 100 scores 1, 100 or above scores 2) is the detail most often misremembered.
| Component | Score 0 | Score 1 | Score 2 |
|---|---|---|---|
| Appearance | Blue or pale | Body pink, limbs blue | Completely pink |
| Pulse | Absent | Below 100 bpm | 100 bpm or above |
| Grimace | No response | Grimace | Cough, sneeze or cry |
| Activity | Limp | Some flexion | Active movement |
| Respiration | Absent | Slow or irregular | Good, strong cry |
The score is a snapshot taken at a point in time, so the one-minute score is often low for reasons that resolve quickly. The five-minute score is the more useful guide, and persistently low later scores carry more weight. A low score is reported together with the minute at which it was recorded, and the score never replaces the cord arterial blood gas when asphyxia is suspected.
Where the exam tries to catch you
Apgar questions test whether the candidate uses the score for what it describes and not for what it cannot show.
- Trap: reading a one-minute Apgar of 3 as permanent brain injury Correct: the one-minute score is often low for reversible reasons, so the five-minute score (and later scores if low) is the better guide.
- Trap: using the Apgar score as the test for birth asphyxia Correct: asphyxia is diagnosed by cord arterial blood gas and clinical criteria, while the Apgar only describes the baby at a time point.
- Trap: believing a low score excludes the need for resuscitation Correct: resuscitation decisions rest on heart rate, breathing and tone at the time, not on the score alone.
Frequently asked questions
What are the five components of the Apgar score?
The five components of the Apgar score are appearance, pulse, grimace, activity and respiration. Each is scored 0, 1 or 2. The total ranges from 0 to 10. Scores of 7 to 10 are generally reassuring.
At what times is the Apgar score recorded?
The Apgar score is recorded at one minute and five minutes after birth. If the five-minute score is below 7, scoring continues at five-minute intervals (10 minutes and beyond). The later scores give a better picture of the baby's status.
Does a low Apgar score prove birth asphyxia?
A low Apgar score does not prove birth asphyxia, because the score describes the baby's condition at the time of scoring. Asphyxia is diagnosed using cord arterial blood gas, the clinical course and other criteria. Prematurity and maternal drugs can also lower the score and need to be considered.
What does the Apgar score predict about long-term outcome?
The Apgar score is a poor predictor of long-term neurological outcome in an individual baby. It is useful for describing the newborn's status and for prompting care. It should not be used alone to predict a child's future development.
How is the pulse scored in the Apgar score?
Pulse is scored as 0 if absent, 1 if the heart rate is below 100 bpm, and 2 if it is 100 bpm or above. It is the single sign that most directly guides resuscitation decisions in the delivery room. Heart rate is checked early and reassessed during the first minutes.